Large MCA Strokes* Although headache is less common in ischemic stroke, the presentation may be deceiving. Some patients with large vessel occlusion will mimic signs of hemorrhagic stroke--headache, vomiting, hypertension, altered mental status.

* Irrespective of the 6-hour window or 3 hour post wake up window, consider paging out a code stroke if you're concerned or hedging. Thrombectomy is to be considered!

* Time is brain. Data suggests there is likely a direct correlation between speed of treatment and better outcomes, particularly with endovascular data.

* Severe digitalis toxicity can rarely result in temporary cessation of atrial fibrillation and the appearance of a slow junctional rhythm without P waves. Occasionally, when the digitalis toxicity improves, the atrial fibrillation returns

* Hyperkalemia, essentially a Na channel blocker, should be considered with all junctional rhythms

* We don't always perform medication reconciliation but an argument could be made that looking at the drug list tells you more about the PMH and PSH than perusing the record

Central line trouble shooting: -- do not force the guide wire -- do not re-use a bent guide wire -- use your ultrasound to confirm placement with modified bubble study -- consider chest x-ray while still sterile to gauge line placement

Modified bubble study for confirming central line placement: 1. Obtain US view of the RA/RV 2. Shake up a flush (without adding air) 3. Rapidly push flush through one of the ports 4. Should see dynamic echogenicity within the RA/RV if venous access

Opioid prescribing by emergency providers affects long term opioid dependency of patients

Opioid prescribing for chronic pain has poor evidence for improved functional outcomes of pain or improvement in pain control over long term.

Emergency providers should explore non-opioid pain management strategies, particularly for chronic pain, and emphasize the importance of a relationship with one provider for those patients seeking long term opioid pain relief.

EPs role in chronic pain should be to reassure patient of the non-emergent etiology of pain, provide resources for further diagnostic workup, and introduce patients to effective non-opioid pain management like physical therapy, cognitive behavioral therapy, meditations, nuerofeedback, and other pain management strategies.